Family questions son's killing

Deputy cleared in shooting, but parents seek answers

As he mulled it over hours later, Deputy Walter Garrison kept coming back to the senselessness of it. He had fully intended to send Kevin Pao on his way after ensuring he didn't have any outstanding warrants.

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But within minutes of laying eyes on the 22-year-old Rockville, Md., native, Garrison shot Pao to death in the back seat of his patrol car.

It happened about 5:30 p.m. on Labor Day last year in the parking lot of Five Guys Burgers and Fries on Washington Road. A Richmond County grand jury heard details of the case April 19 and chose not to indict Garrison on any criminal charges. The sheriff found that to be an affirmation that Pao's shooting was justifiable self-defense.

Pao's family believes it was preventable. His parents find it incomprehensible that their son, who never so much as got into a playground fight, would die in such a situation.

"Because it is so hard for them to believe what happened to Kevin, they still hope to learn more so as to shed light on this inexplicable event," said Atlanta attorney Brian Spears.

On May 20, Spears placed a full-page ad in The Augusta Chronicle asking anyone who knows anything about the shooting to call him.

"It really doesn't make any sense to us," said Pao's father, Steven Pao, in a telephone interview from his Rockville home.

Life at home

From the investigative report filed by the Georgia Bureau of Investigation and interviews with Pao's family, The Chronicle pieced together how Pao and Garrison came together and what happened in the final minutes of Pao's life.

Pao started high school with good grades. He was a star pitcher on the junior varsity baseball team, Steven Pao said.

In his sophomore year, his parents found out he was smoking marijuana with friends. They sent him to live with a relative out of state. Six months later he returned home, but his school performance wasn't the same.

He dropped out and earned a GED from home and started taking classes at a community college. He was a business major with a 3.5 average, his father said. Pao and his wife thought he could do better.

They also expected their son to work at least part-time while going to college. He'd had jobs -- the last was for the U.S. Census Bureau as a sales clerk -- and they knew he was trying to find work because he would wear a suit and tie to go fill out applications, his father said. But they thought he should try harder.

At the end of July, they had a huge argument.

"We said some things we shouldn't have and he said some things he shouldn't have," his father said.

The next morning, while his parents were on a walk, Kevin Pao packed some of his belongings and drove off.

At first, his parents weren't worried. He had run off before and came back after he cooled down. But this time he was gone for weeks and wouldn't answer his cell phone, which they called every day.

They had no idea where he was until a police officer in Augusta called last September.

When the Paos had Kevin's car towed back to Maryland, they discovered the transmission was broken, his father said. His son had been stuck in Augusta and was too proud to call for help, Steven Pao said.

At Five Guys

Raymond L. Almodovar, a manager at Five Guys, told GBI agents that Pao started coming into the restaurant about two weeks earlier, in mid-August.

He'd eat the free peanuts the restaurant provided and drink water, ask other customers for money and wash in the bathroom.

Almodovar complained to the sheriff's office at the end of August. He was told to call the next time Pao showed up. Pao came in Sept. 6, and Almodovar called the police.

Garrison, who had just turned 32 a few days earlier, was writing a report outside another Washington Road restaurant when he heard the call "trouble with customer" at Five Guys. The deputy, who had been with the department for four months, was near the end of a 12-hour shift when he signaled he would take the call.

The manager indicated the customer was in the restroom, and Garrison knocked on the door. Pao opened it so quickly it startled both of them, Garrison said.

"He seemed kind of nervous, more so than someone might normally be (upon) seeing a sheriff's deputy," Garrison told the GBI. He told Pao they needed to talk, that he wasn't under arrest, but that he wanted Pao to come outside with him.

"He said all right," Garrison said.

Garrison let Pao step in front of him and pulled on the strap of the bag that Pao was carrying over his left shoulder. Garrison said he kicked himself for not immediately asking Pao whether he had any weapons in the bag. He worried when Pao tried to reach into the bag as they were walking out of the restaurant.

Garrison said he grabbed Pao's left arm as they walked out. He told Pao again that he wasn't under arrest and that they just needed to talk. "He was really getting fidgety."

Pao wasn't handcuffed because he wasn't under arrest.

In the patrol car

Several people saw Garrison escorting Pao to the patrol car and saw what they believed was the two men fighting in the back seat because the car was rocking. At least two witnesses told GBI agents that Pao was the aggressor, which is contrary to Garrison's account.

There was a big problem at the car, Garrison said. He sat Pao in the back seat and asked whether he had any weapons. Garrison said that's when Pao started to pull at his bag and try to reach inside it.

Garrison said he went after the bag, trying to keep Pao from getting a hand inside. He grabbed Pao from the back to restrain both of his arms but lost his grip.

"I'm thinking he has a gun in the bag or some type of weapon in the bag," Garrison said.

He said he dove into the car on top of Pao and used his baton to hit him on his head and his back. Pao turned toward him with something white in his hand.

To Garrison, it looked like what a gun would look like if you held one in your hand and draped a white towel over it, he told the GBI.

"From that point that I saw that to the point I drew, honest to God, I thought I was fixing to die," Garrison said.

He dropped the baton and fired his gun four times.

Two shots went through Pao's left arm and into his chest, according to the autopsy report. A third struck directly into his chest. A fourth bullet, fired close enough to leave powder burns, went into Pao's upper back. The sequence of the shots could not be determined, according to the medical examiner.

Plan to release Pao

It had all started for Garrison like he learned in the police academy. He had a plan in his head for how he would deal with Pao. He was going to take Pao outside to check for outstanding warrants and if he didn't find any, he was going to release Pao, he said.

"Technically he hadn't broken the law by going in there. They just didn't want him in there," Garrison said. "I had all intentions of just letting him go on his way."

That's what should have happened, said one of the attorneys representing the Pao family.

"Mr. Kevin Pao's shooting death was preventable," Spears said. Garrison should have asked about and secured any weapon at the beginning of the encounter, Spears said.

According to the GBI report, Pao died in the back seat of the car. The bag was beside him with what looks like a strap across his torso. Between his legs was a white T-shirt with the openings sealed shut with duct tape. Inside the makeshift package was a .22-caliber handgun.

Pao bought the gun legally March 25, 2009, in Rockville. He had practiced shooting at least once, according to a receipt from a shooting club found in Pao's car two days after his death. A search of the 2002 gray Ford Escape also revealed copies of his résumé, cover letters and job applications, along with electronic and musical equipment, his identification and a samurai sword.

Pao loved music and wrote many songs, his father said. He hoped to find a career in the music industry.

Steven Pao didn't know his son had a gun. He would have taken it away if he had known.

He said he cannot imagine his son trying to use a gun against an officer. He respected law enforcement officers, Pao said.

Garrison, who put himself through the law enforcement academy and received his police officer certification April 20, 2010, was hired for his first law enforcement job at the sheriff's office May 1, 2010. He was assigned to desk duty after the shooting but returned to regular patrol duty two months later.

The Pao family is consulting with their lawyers to evaluate the GBI report, Spears said. They haven't decided on any possible action at this time.

"We had high hopes with Kevin," Steven Pao said. "He was a talented boy. He was a hard-working boy."

Learn more

Go deeper into the case:

AUDIO: To listen to the recorded statement of the officer who fatally shot Kevin Pao, click the Video tab above the photos to the left of the story.

DOCUMENTS: Review the Georgia Bureau of Investigative report and additional documents related to the case. The district attorney's office and The Augusta Chronicle have redacted personal information such as dates of birth, Social Security numbers, home addresses and phone numbers.

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It sounds like The Pao family may have a very good case. This is a case where a death could have easily been prevented if proper protocal had been followed. #1 The bag should have been checked from the outset. #2 Mr Pao should have been handcuffed, regardless of whether he was under arrest or not. If someone is going to be placed in a patrol car, it is proper procedure to handcuff that individual, regardless of whether they are under arrest. In fact it is common procedure to handcuff any mental patient being transported to a hospital in a patrol car (who is not under arrest).. this is done for the safety of the patient and the officer.
#3.. Mr Pao should have never been allowed to keep possession of the bag in the patrol car. If the officer had a fear that a weapon may be present, he should have ascertained whether there was one one checking the bag and getting it out of the hands of Mr Pao.
Hopefully this incident will cause the sheriff to update their training for new officers. It sounds like this case could end up costing the sheriff's dept a lot of money, because proper protocol and procedure were clearly not followed in this incident.

The Sheriff ruled the shooting justified. The GBI ruled the shooting justified. The grand jury ruled the shooting justified. ANY deputy placed in the same situation would certainly hope that they would be prepared to fire their weapon prior to the suspect firing his and EVERYONE should be happy that when it is one life or another that the officer is the one who lives.

Based on your statements you haven't a clue what proper protocol is. When a deputy goes to search a bag without probable cause, you can rest assured that reporters such as the one that wrote this article would be attacking him for violating the person’s rights. As for "he should have been handcuffed" - that is absolutely contrary to RCSO arrest policies and procedures - should deputies just start searching ALL persons they come into contact with that haven’t even broken the law as of yet and search them fully as well as their belongings until they run a background check on the radio? Really? I'm not sure where you are getting your propaganda but your statements are as far from true and accurate as they can possibly be.

No matter what incident and officer is involved with you can always second guess the situation afterwards. However, the officer did not violate ANY procedures and all other decisions made are judgment calls to be made by the officer at the scene dealing with everything, not some reporter or others afterwards.

This is the 3rd type of negative law enforcement "article" written by Sandy Hodson. Her use of "A Richmond County grand jury heard details of the case April 19 and chose not to indict Garrison on any criminal charges. The sheriff found that to be an affirmation that Pao's shooting was justifiable self-defense." Instead of actually reporting the truth - Deputy shoots armed suspect while in the performance of his duties.

Deputies do not need to second guess their selves continually (they do that enough already) but they sure as heck don't need ill informed non law enforcement trained individuals or reporters trying to see into the past and condemn them for every breath they take.

Taking a life is a very difficult decision for one who is sworn to protect and serve. Everything usually happens in a matter of seconds and often times it is the officer who is dead - then the newspaper actually writes something nice about them, isn't that special.

Prevention...Yesh, this could have been prevented if Pao was not trespassing at Five Guys. This could have been prevented if Pao had not returned to Five Guys after being told not to do so. This could have been prevented if Pao would have followed the simple requests of the deputy. This could have been prevented if Pao wasn't reaching for a gun while an officer was trying to bring him under control. Yes, this certainly could have been prevented. Other than Pao being a law abiding citizen and not placing one of this communities deputies in harms way this result was inevidible and properly carried out.

Bottom Line....Pao was appropriately contacted by police who were called to a situation. While this officer was simply trying to effectively do his job, Pao chose to take an aggressive approach and remove a firearm from a bag placing this officer in a life or death situation - ALL of his training says to draw and fire and that is what he did.

This community is lucky to have officers such as Deputy Garrison who do their jobs effectively and Sheriff Strength who supports his deputies when they do their jobs well and disciplines those who don't. While the death of any person should never be taken lightly, individuals such a Pao place their selves in that situation and thank goodness we have deputies that respond appropriately.

Why any reporter or individual would side with an armed individual failing to cooperate with the police vs. a sworn police officer simply trying to effectively do his job is beyond comprehension.

God Bless Deputy Garrison and the many others who place their lives on the line every day!

Hmm I am a bit late on this whole case, but a criminal case and a civil case are 2 very different things. Were the officers actions "criminal"? absolutely not. I am sure he did feel in danger. But the greater question is whether the officer could have diffused the situation early. Even the officer admits that he should have asked Mr Pao from the outset whether he had any weapons on him. This is always one of the first things any officer should ask in this kind of situation. The officer clearly admits failing to do this. Now I am not sure what RCSDs policy is, but I can tell you that for most other law enforcement agencies if anyone is being put in the back of a patrol car for whatever reason, they are always handcuffed for safety purposes. This should have been done while the officer was checking for priors and any warrants. As far as checking the bag, the officer should have first asked Pao whether he had any weapons and then if he COULD check the bag. It does not appear that the officer made any effort to do this. And Mr Pao should not have been allowed to take the unsearched bag into the back of the patrol car.. it could have been left on the curb or put in the trunk until after more information was gathered. This is how this should have been handled. If this is not the protocol for the RCSD then maybe they need to update their procedures to be inline with those of most other law enforcement agencies. Again, a grand jury was looking for any criminal fault.. I agree with their findings.. the officer should not be held criminally liable. But a civil case is different. It involves compensatory damages and will dwell on whether this could have been prevented if proper procedures were followed.

the proper procedure here would have been to do what's called an "investigative detention".. that doesn't mean Mr Pao is put under arrest, but simply temporarily detained until more information is gathered. It seems that is what the officer was trying to do by placing Mr Pao in the back of the cruiser. In any case, proper procedure would have been to pat Mr Pao down for any weapons, separate him from the bag and place him in cuffs while the officer performs an investigation. It seems clear that there was probably cause to perform an investigative detention. There were a whole series of steps not followed in this case.. that could have put the officer's life and those in the vicinity in danger.

bottomline.. I have never heard of a situation where someone being put in the back of a patrol car was not handcuffed first.. this is routinely done for safety reasons. If this is not protocol for the RCSD, then sheriff strength needs to revise his procedures manual because this is a recipe for disaster, and in the future, more people could be harmed.

I don't see a case here unless you count the lawyers lurking in the background. Whether the deputy followed department procedures in handling the matter, the bottom line is if Mr Pao had simply complied with the officer's instructions he might be alive today.

Even if the deputy ignored policy, the existence of a handgun disguised as a T-shirt removes all doubt s to whether the officer should have felt a lethal threat to his life.

The deputy had a lethal threat to his life. He was justified in shooting the guy. Why is it that when a cop gets a gun pulled on him and he shoots back the one that always pulls the gun is such a sweet boy who never got into a playground fight? Or why is it that people expect the cop to diffuse a situation where a gun is pulled on him without shooting? Thats why they give them guns.
Maybe the cop isnt jaded that everyone is a killer, or at least he wasnt...and figured this was just a situation where they were going to have a man to man talk. For all I know, he let the kid sit in his car so that he would have a place to sit. None of us knows...except that cop.
I grew up being taught that if the police tell me to do something I just do it. Dont make sudden moves, dont make the cops nervous. If Mr. Pao had done just those couple things, maybe he would still be here. And...in closing...just what does anyone suppose this kid was going to do with a gun concealed in a t-shirt?? His parents might also want to think about that...a "good kid that never got in a playground yet feels the need to carry around a concealed gun" is up to no good to start with.

It is at the deputies discretion as to whether to handcuff a person or not. I am sorry the Pao's lost their son but he should have volunteered he had a concealed weapon. I agree with another poster, can you imagine the cries of civil rights violation if every person a officer came into contact with was searched and handcuffed? I also agree that I was taught when you come into contact with a police officer you obey his commands and do not make sudden moves or stupid actions that could make him think his life is in jeopardy. I am sure the Pao's want answers and, as a parent I would too, but the bottom line is their son made a huge mistake that cost him his life.

yes, obviously the situation escalated to a point where the officer felt a threat to his life. The question is, did it have to escalate to that point? If the officer had followed proper procedure from the outside, I doubt it would have escalated to that point. That means proper questioning of the subject from the beginning, patting the subject down for any weapons (this was clearly not done and the officer admits it), this means handcuffing the subject BEFORE putting them in back of a patrol car. I have never heard of any police dept where it is standard practice do just let a subject sit in the back of a police cruiser unrestrained and with a backpack that had not been searched. The evidence does not make it clear that a gun was ever pointed at the officer, just that one was "found" in the bag and the officer thought the subject might have had a gun. No where does it say a gun was found in the t-shirt.. but rather was found somewhere in the bag. BUt this could have been avoided if the officer performed a "pat-down" from the beginning and separated the subject from the bag, BEFORE he ever got into the back of the cruiser. How do we know the subject would not cooperate with the officer? What was his line of questioning? Did the officer try and do a pat down and did he ask to search the bag and the subject refused? That is not clear from the report, because it appears that the officer never tried to retrieve the bag until after the subject was in the car, and the officer admits that he failed to ask the subject if he had any weapons in his possession. What happened here was very unfortunate, but perhaps could have been prevented if a more by the book approach was taken. There was a series of missteps in how this was handled. I respect immensely what our law enforcement personnel has to deal with and how they put their lives on the line, this is why they need the best training to ensure that situations such as these can be diffused safely. perhaps a few simple questions, a pat down, and handcuffs could have kept this situation from escalating to the point it did.

According to the GBI report, Pao died in the back seat of the car. The bag was beside him with what looks like a strap across his torso. Between his legs was a white T-shirt with the openings sealed shut with duct tape. Inside the makeshift package was a .22-caliber handgun.

You keep saying if the officer followed proper procedure. He did, It is the officers discretion whether to search or handcuff someone. He was cleared by the Sheriff, the GBI and a grand jury. Obviously he followed procedure. Hindsight is 20/20 but this officer did nothing wrong other than defend himself from a person carrying a concealed weapon!!

I'm sorry, but if you as an officer felt that there was discretion to put the subject in the back of the police cruiser, while completing the investigation (this is called investigative detention) then it is proper procedure to handcuff the subject.. and before that pat-down the subject... this does not mean the subject is under arrest. This is routinely done for both the safety of the officer and the subject and others in the vicinity, because you just never know who you are dealing with. These simple procedures were not followed plain and simple. In the future they should.

You keep contradicting your own statements...I have been pulled over for speeding and put in the back of the patrol car and not handcuffed...I will say it one more time IT IS THE OFFICERS DISCRETION!!!

I many jurisdictions it is always proper procedure to handcuff anyone being placed in the back of a police vehicle. In this case obviously the officer didn't use good discretion. This is why you have to have proper procedure..and not just discretion.. that is why it is mandatory in many departments to handcuff subjects in these situations..sheriff strength needs to look at making this procedure in RC.. for the safety of his own officers and those in their custody

Actually the reason I was put in the back was I got out of my car before the officer got out of his...I was a kid and didn't know it was a big no no...I was going 72 in a 55. He explained to me how bad of an idea it was to exit my car and I learned a valuable lesson.

Only in America were you can work for a law enforcement agency and legally use deadly force and the grand jury,in southern states, always clear deputies of killing a cititzens and most of the time the killing are unjustified. The pattern, in America, i see is most of these deputies are cowards,they belong to the European race, and always involved with a shooting incident and the victims are African American. The grand jury know that a officers chances of surviving in a jail or prison is slim and they can't use a gun when you are in the can. So, do the police academy teach deputies enough training to defend themselves (with their hands) if they're put in prison population with Big Tyrone? And why the America people never read or heard in the news about a African American police officers,across the fifty states, involve in a deadly shooting incident and the victim was a european? But you always see and heard in the news a European officers cleared by the grand jury of shooting death of a African American who reach to showed his wallet or using his vehicle to fled the scene.
May God Bless America!~

You can armchair quarterback this all you want. The only persons that could have made the decisions made them. The boy made his and Deputy Garrison made his. I cannot believe the gall some people have in thinking they know everything. What gives you the right to come on here and preach that you know what should have been done in this situation unless you were standing in that Deputy’s shoes at that exact moment! You do not know what way the wind was blowing or if the there was chill in the air and you certainly do not know any and everything that was going on in that officers head or that young man’s head at any point in this entire matter. I know if it were me I would rather be tried by twelve then carried by six any day so what happened happened and I’m sure most other cops will back up that statement with me. I am sorry for the parents for the loss of their child but putting the Deputy through even more pain after having to take a life while on the job by them taking out a FULL PAGE AD is just wrong and they should be ashamed of themselves!! They themselves admitted in the interview that they pushed their son to the point of leaving and breaking. They themselves said he wasn’t good enough. A 3.5 GPA isn’t perfect but it is pretty good in my book and he was trying to go find a job (in a suit mind you) but that wasn’t good enough for them either. So let’s see where we can spread some of this blame around a little. Nobody is perfect. If the Deputy is liable for taking the life with the actions he took for putting Poa in that situation so are his parents for pushing him to the point of leaving his house I say. It’s all absurd at this point!

It's not arm chair quarterbacking.. it's learning from the mistakes in this incident so that they are NOT repeated in the future. There were a whole series of events between the officer arriving on seen with the subject in the restroom to the subject being placed in the patrol car and then the officer discharging his weapon. Between the subject exiting the restroom and being placed into the patrol car there were several crucial steps not taken by the officer, steps that are routine procedure in most police departments throughout the country. Why are they routine procedure? To protect the officer, the subject and and bystanders in the immediate vicinity? I would like to know exactly what are the standard operating procedures for the RCSD in these types of situations? One of the very first things an officer should ask any subject is whether they have any weapons (especially in a situation like this where there is a probability of a mentally unstable individual).. then pat the subject down for any weapons.. If the subject is going to be put under temporary investigational detention (and putting them in the back of the patrol car constituted that) then before placing them in that car, the subject should have been handcuffed... that simple act would have prevented the following events from occcuring. Again, this is standard operating procedure for most police depts under these kinds of situations. If it is not for RCSD.. then it needs to be.. because we don't need more incidents like this. What if the subject had succeeded in shooting the officer and bystanders? The fact is you have to treat these situations as though the subject may pose a threat.. and the proper steps should be taken so they don't escalate to the point of actually becoming a threat. No one is saying the officer should go to jail or lose his job.. but fact remains that if basic protocol had been followed this would never have escalated to the point it did. Now what I want to know is will the dept learn from this incident and revise their procedures or willl they just shrug it off as an unfortunate accident?

I would have been shocked if Pao's family had not pursued this matter, as any decent parent would.

It does sound like a combination of unfortunate events took place that lead to this tragic outcome. You can argue all day long regarding proper procedure, but the bottom line is the deputy was tired, inexperienced and fearful from the moment he stepped into the restroom, by his own admission. He also placed himself and others in harm's way by placing him in the car with the bag.

This is not meant as criticism towards the officer. Law enforcement officers place their lives on the line for us every day and they deserve the benefit of the doubt. But that does not mean that we should turn a blind eye when things go wrong and innocent people are harmed.

No amount of justification changes the fact that this was an unnecessary death. I wish the best for both Garrison and the Pao's family as they continue to find peace in this matter. And hope that this event will not be wasted, but used as training for law enforcement.

Sheriff Strength would have so much more credibility if he would come forward and say that different precautions will be taught and administered by his department.

Emerydan if you want to know the procedures so bad why don’t you go and get a job with the RCSO and then you can find out firsthand what they are and what they have to deal with on a daily basis. You yourself just said this is standard SOP for MOST Police Agencies. It is not SOP for all so unless you plan on going to every and all Police Agency in the US that has had an Officer involved shooting then lay off. Just because you get on here and rant and rave and act all big and mighty because you think you have a right to and have a pen and an opinion still just makes it that... YOUR OPINION!
And Willow how is that not supposed to be taken as criticism towards the officer??

This is some information for those who believe that Pao should have been searched before he was placed in a patrol car. He was not under arrest and the Deputy had no RAS that a crime was being committed. Five Guys simply wanted him removed from the restaurant. Unless Pao agreed to let the Deputy search through his belongings the Deputy could not. It would be a violation of his 4th amendment rights. You also might be walking a fine line with unlawful detention if he was handcuffed and put in the back of the patrol car.

To the author of this article. We do not have police departments in this part of Richmond County. It is offensive to call the Sheriff's Office the police.

that is simply not true.. even if the subject was not under formal arrest, the officer can ask if the subject has any weapons (that should have been the first step.. that was not done), you always ask to search for weapons.. if a subject is not under arrest, they can refuse.. but you always ask (was this done, apparently not.. and how do we know the subject would not comply).. and the officer was well within his rights to handcuff the subject before putting him in the patrol car. When the officer said he was worried when the subject was tugging on the bag, and because he did not ask the subject whether he had any weapons.. that would have been the point where he could have handcuffed Pao, for his own safety (this is clearly within the law). If he was worried about Pao's behavior (which he describes as far more nervous and agitatated than someone should be at encountering a police officer) and of possibly having a weapon in the bag (which had not been searched) then at that point things had changed.. to a situation where the subject could possibly be a threat to himself or others and in that case an officer is well within their rights to restrain a subject. Bottomline, the subject should never have been placed, unrestrained in that car with posession of that bag. But as others have said, he was coming off a 12 hour shift and was a rookie.

Emerydan did you not read the article? The Deputy stated that his intentions were to let Pao go after searching to see if there were any warrants on him. So he obviously did not feel like the man was a danger to him at the point of contact. I never said the Deputy could not ask Pao if he had any weapons. I said that unless Pao agreed to a search they would be violating his 4th Amendment rights. They can ask him anything they want, but Pao did not have to answer.

Common.sense, i agreed thats so truth;however, African Americans are more subject to be asked permission for a search "anyway' if they are not under arrest. Common things deputies ask African American if they are giving consent to search. "can i search your car," and "can you spread your butt cheeks".
So, i do not know was Kevin Pao black or white but i can say if the deputy would have followed proper training procedures and asked to search the bag before he put him in the back seat this death could have been avoided.